Evidence-based guideline: Management of an unprovoked first seizure in adults

Clinicians should inform the patient that the chance for a recurrent seizure is greatest within the first 2 years (21%–45%), with the highest risk in the first year (32% at 1 year, compared with 46% by 5 years).

Clinicians should identify if there was a prior brain insult or lesion (e.g., stroke, trauma, CNS infection, cerebral palsy, cognitive developmental disability) judged to be the cause of the seizure (remote symptomatic seizure).

The risk of recurrence is approximately 2-fold higher, with cumulative incidence rates of 26%, 41%, and 48% at 1, 3, and 5 years, respectively.

An EEG should be performed to check for epileptiform abnormalities (spikes or sharp waves).

The risk of seizure recurrence is significantly increased (relative rate increase of 2.16; 95% CI 1.07–4.38).

Significant brain-imaging abnormalities (MRI or CT) judged to be the cause of the seizure should be identified.

The hazard ratio for seizure recurrence is increased to 2.44 (95% CI 1.09–5.44).

The clinician should determine if the seizure was nocturnal.

The risk for recurrence is increased (odds ratio 2.1; 95% CI 1.0–4.3) compared to seizures occurring while awake.

The patient's age, sex, family history of seizures, seizure type, and presentation with status epilepticus or multiple discrete seizures within 24 hours are not consistently associated with increased recurrence risk.

Clinicians should advise that immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce the risk of a seizure recurrence within the first 2 years (absolute risk reduction of about 35%).

Patients should be informed that immediate therapy may not improve quality of life (QOL) measures.

Clinicians should advise that immediate AED treatment is unlikely to improve the prognosis for sustained seizure remission compared with treatment delayed until a second seizure occurs.

Patients should be informed that the risk of adverse events (AEs) ranges from 7% to 31%.

Patients should be advised that these are likely predominantly mild and reversible with dose reduction or drug switching.

Initial AED monotherapy with phenytoin or topiramate is associated with AEs leading to discontinuation in only 7% to 13% of patients.

Clinicians' recommendations should be based on individualized assessments that weigh recurrence risk against AEs, consider patient preferences, and explain that immediate treatment reduces short-term risk but does not improve long-term remission rates.

Appropriate evaluation to determine if the seizure is unprovoked or symptomatic is required before management decisions.